Fournier’s Gangrene: 10-Year Experience of a Plastic Surgery and Burns Department at a Tertiary Hospital

Abstract

Introduction: Fournier gangrene is a polymicrobial life threatening infection of perineal subcutaneous soft tissues with its point of origin in urologic, colorectal or skin diseases. Although more frequent in elderly and men, it can affect all genders and age groups. Perianal abscess, diabetes mellitus and Escherichia coli are the most frequent cause, predisposing comorbidity, and microorganism found in tissue culture analysis respectively. The objective of this study was to describe the experience of a Plastic Surgery Department of a tertiary Hospital in reconstructing Fournier’s gangrene perineal defects and its detailed demography.Material and Methods: The sample is composed of all patients with Fournier gangrene admitted in the Plastic Surgery and Burns Department. The authors retrospectively collected and analyzed demographic and clinical data during a period of 10 years including gender, age, length of stay, cause, number of debridements, predisposing factors, microbial culture results, surgical reconstructive techniques and its associated complications, additional surgical procedures and outcomes.Results: Fifteen patients were identified: 14 males (93%) and one female (7%); mean age was 66.9 years (range: 46 - 86); mean, length of stay was 46.8 days (range: 20 - 71 days) and mean number of debridements was 3.3 (range: 1 - 4). The most frequent predisposing factor was diabetes mellitus, the major cause was perianal (n = 2) and skin abscess (n = 2). Eight (53.3%) patients had no identifiable source of Fournier gangrene. Various types of reconstructive techniques were employed; and 5 additional surgical interventions (33.3%) were undertaken (one cystostomy, two orchidectomy, two ileostomy); six patients (40%) presented reconstructive technique complications with adequate final outcome.Discussion: In contrast with the literature, where Escherichia coli was the most frequently isolated agent, Staphylococcus aureus was the most frequent microorganism found in tissue biopsy/pus collection analysis. A higher than expected number of patients (n = 8) had no identifiable source of Fournier gangrene. This findings can be explained by the retrospective non-multicentre study limitation, with a potencial source of bias patients that were transferred from other hospitals in advanced stage, without point of origin of Fournier’s gangrene identified.Conclusion: Early recognition and extensive necrotic tissue debridement, along with prompt and adequate antimicrobial treatment, are the mainstay of Fournier gangrene management, thus reducing morbidity and mortality in these patients. Surgical reconstruction challenges derived from this condition should be addressed by specialized teams due to the risk of dysfunctional sequelae and conspicuous deformities. Taking in account the single-center and retrospective observational character of the present study, these premises require proper validation from a multicenter prospective study.

Fournier’s Gangrene in Patients with Oncohematological Diseases: A Systematic Review of Published Cases

“…Further assessment of eligibility, based on full-text papers, led to the exclusion of nineteen papers. Finally, 35 papers (6 case series and 29 case reports) involving a total of 44 patients were included in the final analysis ( Figure 1 ) [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ].…”

Necrotising fascitis - a life-threatening infection: Case reports and literature review

“…Most commonly it is a polymicrobial infection caused by aerobic and anaerobic bacteria, most commonly from the genitourinary and digestive tract, but also from the skin [7]. However, some recent studies suggests that the prevalence of monomicrobial NF is as high as 60-80% [8].…”

Gangrena de fournier com complicações em lactente do sexo feminino: Um relato de caso / Fournier's gangrene with complications in a female infant: A case report

“…Diabetes mellitus, alcoolismo crônico, terapia imunossupressora e desnutrição são mais observados em adultos. Na infância, raramente ocorre de forma idiopática e são importantes os seguintes fatores: prematuridade, trauma, higiene precária, assaduras, queimaduras, picada de inseto, patologia anorretal ou periuretral, hérnia estrangulada, herniotomia, fimose, parafimose, circuncisão, onfalite, infecção por varicela, procedimentos na região perineal, instrumentação da uretra, distúrbios do sistema imunológico, neoplasias hematológicas e infecções sistêmicas 1,2,3,4,5,6,7,10,12,13 . No presente relato não houve causa identificável.…”

“…Essas toxinas promovem lesão tecidual e acometimento de todas as camadas da derme gerando uma fasceíte superficial e profunda. Posteriormente, ocorre endarterite obliterante responsável pela trombose vascular e consequente necrose tecidual 1,2,3,4,7,12,13 .…”

“…Na infecção, o mais comum é a presença de flora mista. A não identificação do agente etiológico, como no presente relato, pode ser explicada pela administração de terapia antimicrobiana antes da coleta de culturas, com resultados falsos negativos 4 .…”